CASE REPORTS / CASE SERIES

Low thoracic erector spinae plane block for perioperativeanalgesia in lumbosacral spine surgery: a case series

Bloc du plan des muscles erecteurs du rachis thoracique bas pouranalgesie perioperatoire dans la chirurgie du rachis lombosacre :une serie de cas

Josh P. Melvin, MD . Rudolph J. Schrot, MD, MAS, FAANS . George M. Chu, MD .

Ki Jinn Chin, MBBS (Hons), MMed, FRCPC

Received: 22 February 2018 / Revised: 21 March 2018 / Accepted: 21 March 2018 / Published online: 27 April 2018

� Canadian Anesthesiologists’ Society 2018

Abstract

Purpose Severe postoperative pain following spine

surgery is a significant cause of morbidity, extended

length of facility stay, and marked opioid usage. The

erector spinae plane (ESP) block anesthetizes the dorsal

rami of spinal nerves that innervate the paraspinal muscles

and bony vertebra. We describe the use of low thoracic

ESP blocks as part of multimodal analgesia in lumbosacral

spine surgery.

Clinical features We performed bilateral ESP blocks at

the T10 or T12 level in six cases of lumbosacral spine

surgery: three lumbar decompressions, two sacral

laminoplasties, and one coccygectomy. Following

induction of general anesthesia, single-injection ESP

blocks were performed in three patients while bilateral

continuous ESP block catheters were placed in the

remaining three. All six patients had minimal

postoperative pain and very low postoperative opioid

requirements. There was no discernible motor or sensory

block in any of the cases and no interference with

intraoperative somatosensory evoked potential monitoring

used in two of the cases.

Conclusions The ESP block can contribute significantly to

a perioperative multimodal opioid-sparing analgesic

regimen and enhance recovery after lumbosacral spine

surgery.

Resume

Objectif Une douleur postoperatoire severe apres la

chirurgie de la colonne vertebrale est une cause

importante de morbidite, de l’allongement de la duree de

sejour en etablissement de soins et d’une utilisation

marquee du recours aux opioıdes. Le bloc du plan des

erecteurs du rachis (PER) permet une anesthesie des

rameaux dorsaux des nerfs rachidiens innervant les

muscles paravertebraux et les vertebres. Nous decrivons

des blocs du PER thoracique bas dans le cadre d’une

analgesie multimodale pour chirurgie du rachis

lombosacre.

Caracteristiques cliniques Nous avons pratique des blocs

du PER aux niveaux D10 ou D12 dans six cas de chirurgie

du rachis lombosacre : trois decompressions lombaires,

deux laminoplasties sacres et une coccygectomie. Apres

induction de l’anesthesie generale, un bloc du PER en une

seule injection a ete pratique chez trois patients tandis que

des catheters bilateraux pour blocs du PER ont ete mis en

place chez les trois autres patients. Les six patients ont

presente une douleur postoperatoire minime et n’ont

necessite que tres peu d’opioıdes postoperatoires. Il n’y a

pas eu de bloc moteur ou sensitif discernable dans aucun

des cas ni aucune interference sur le suivi des potentiels

evoques somatosensoriels peroperatoires utilises dans deux

cas.

J. P. Melvin, MD � R. J. Schrot, MD, MAS, FAANS �G. M. Chu, MD

Sutter Medical Center, Sacramento, CA, USA

R. J. Schrot, MD, MAS, FAANS � G. M. Chu, MD

College of Osteopathic Medicine, Touro University California,

Mare Island, Vallejo, CA, USA

K. J. Chin, MBBS (Hons), MMed, FRCPC (&)

Department of Anesthesia, Toronto Western Hospital, University

of Toronto, McL 2-405, 399 Bathurst St, Toronto, ON M5T 2S8,

Canada

e-mail: gasgenie@gmail.com

123

Can J Anesth/J Can Anesth (2018) 65:1057–1065

https://doi.org/10.1007/s12630-018-1145-8

Conclusions Le bloc des muscles erecteurs du rachis peut

contribuer de maniere significative a un traitement

multimodal analgesique diminuant l’utilisation des

opioıdes apres chirurgie du rachis lombosacre.

Lumbar spine surgery is a common procedure associated

with severe postoperative pain1 that, if poorly controlled,

can increase complications and delay recovery. Opioids are

the mainstay of therapy but are associated with adverse

effects and a risk of long-term habituation and

dependence.2

Regional analgesia techniques can play a significant role

in multimodal analgesia,3,4 but descriptions of their use in

spine surgery are sparse.5-7 The erector spinae plane (ESP)

block technique was first described for thoracic and

abdominal analgesia via its action on the ventral rami of

spinal nerves.8,9 Nevertheless, it also anesthetizes the

dorsal rami, which innervate the paraspinal muscles and

vertebrae (Fig. 1). In this report, we describe our

adaptation of the ESP block to provide perioperative

analgesia as part of a multimodal opioid-sparing regimen in

a series of six patients undergoing lumbosacral spine

surgery.

Description of the ESP block and intraoperative

anesthetic care

All blocks were performed with the patient in the prone

position after induction of general anesthesia. The skin was

disinfected with 2% chlorhexidine in 70% alcohol. Surface

anatomy or ultrasound (counting up from the 12th rib) was

used to identify the appropriate thoracic level and a high-

frequency linear-array ultrasound transducer (SonoSite

Edge, Bothell, WA, USA) covered in a sterile sleeve was

placed in a longitudinal parasagittal orientation 3 cm lateral

to the midline to identify the tip of the transverse process

(Fig. 2A). A 21G 100-mm block needle (Pajunk,

Geisingen, Germany) was used for single-injection blocks

and an 18G catheter-over-needle set for continuous blocks

(E-cath Plus; Pajunk, Geisingen, Germany; this catheter

extends a fixed distance of 15 mm beyond final needle tip

position). The needle was inserted in plane with the

ultrasound beam in a cranial-to-caudad direction to gently

contact the transverse process (Fig. 2B). Correct needle tip

position was signaled by linear spread of the injectate

solution (20-30 mL in total) separating the erector spinae

muscle from the transverse processes (Fig. 2C and 2D).

This process was repeated on the other side.

General anesthesia was maintained with propofol

infusion 55-100 lg�kg-1�min-1 iv titrated using a

Sedline� brain function monitor (Masimo, Irvine, CA,

USA) to achieve a patient state index of 25-50 and bilateral

spectral edge frequencies of 6-12 Hz. Rocuronium

provided muscle relaxation for intubation in all cases. All

patients were extubated prior to transport to the post-

anesthesia care unit (PACU).

The bilateral ESP block catheters (Fig. 3) were

connected in the PACU to two electronic infusion pumps

(SapphireTM, Hospira, ICU Medical, San Clemente, CA,

USA), which were each programmed to deliver patient-

controlled boluses of 10 mL 0.2% ropivacaine at a lockout

interval of 90 min with no background infusion. Patients

were instructed to initiate boluses every 90 min when

awake and at least every three hours during periods of

sleep. Compliance was assisted by the use of the timer on

patients’ smartphones and reminders from nursing staff.

Case descriptions

Written informed consent was obtained from all patients

for this report. Clinical details are summarized in the

Table.

Fig. 1 Graphic illustration of the erector spinae plane block. Local

anesthetic is injected between the erector spinae muscle and the tip of

the transverse processes. This anesthetizes the dorsal rami of the

spinal nerves and their branches that innervate the paraspinal muscles

and bony vertebrae. (Image adapted and used with permission from

Maria Fernanda Rojas Gomez)

1058 J. P. Melvin et al.

123

Patient 1

A 73-yr-old female underwent an L2-L3 lumbar spine

decompression with Coflex� interlaminar stabilization

(Paradigm Spine, New York, NY, USA).10 She was

taking hydrocodone/acetaminophen 10/325 mg several

times per day for lower back pain. She received bilateral

single-injection ESP blocks at T12 with 30 mL 0.375%

bupivacaine and 2 mg dexamethasone per side. Additional

intraoperative analgesics included hydromorphone 1 mg iv

at induction, acetaminophen 1 g iv, and ketamine 20 mg iv

pre-incision. Wound infiltration using 10 mL 0.5%

bupivacaine with 5 lg�mL-1 epinephrine was performed

at surgical closure. The patient reported 0/10 pain on an 11-

point numerical rating scale11 (NRS; 0 = no pain, 10 =

worst pain imaginable) in the PACU. Neurologic

examination revealed full motor strength and normal

sensation to pinprick in both lower extremities. The

patient was continued on acetaminophen 1 g iv six hourly

for the next 48 hr and opioids as needed. During the first 24

postoperative hours, her NRS pain scores ranged from 2-4/

10 and she received one dose of morphine 4 mg iv, 13 hr

after surgery. During the next 24 postoperative hours, her

NRS pain scores ranged from 0-6/10 and she received three

doses of morphine 4 mg iv. During postoperative hours 48-

72, her NRS pain scores ranged from 0-6/10 and she

received six doses of oral hydrocodone/acetaminophen 10/

325 mg. She was discharged home on the third

postoperative day.

Patient 2

An 81-yr-old female underwent sacral laminoplasty and

microsurgical repair of two Tarlov cysts. She reported

sensitivity to opioids resulting in significant nausea and

vomiting. She received bilateral single-injection ESP

blocks at T12 using 23 mL 0.375% bupivacaine and 2

mg dexamethasone per side. Additional intraoperative

analgesics included hydromorphone 1 mg iv at induction

and wound infiltration using 10 mL 0.25% bupivacaine

Fig. 2 A) The ultrasound transducer is placed in a longitudinal

parasagittal orientation approximately 3 cm lateral to the midline to

visualize the tips of the transverse processes (TP) deep to the erector

spinae muscle (ESM). B) The block needle is inserted in plane in a

cranial-to-caudal direction to contact the TP. C) Injection of local

anesthetic (LA) lifts the ESM off the TPs. D) Cranial-caudal linear

spread of LA is clearly seen, separating the ESM from the TPs

Erector spinae plane block in spine surgery 1059

123

with 5 lg�mL-1 epinephrine at surgical closure. Her NRS

pain score in the PACU was 0/10. She had normal motor

strength and sensation in the lower extremities on

neurologic testing. The patient was continued on

acetaminophen 1 g iv six hourly for the next 48 hr and

did not require any opioids during her hospital stay. Her

NRS pain scores ranged from 0-2/10 and she was

discharged home on the third postoperative day.

Patient 3

A healthy 46-yr-old male presented for coccygectomy. He

received bilateral single-injection ESP blocks at T12 using

27 mL 0.375% bupivacaine and 2 mg dexamethasone per

side. Additional intraoperative analgesics consisted of

fentanyl 100 lg iv at induction and wound infiltration

using 10 mL 0.25% bupivacaine with 5 lg�mL-1

epinephrine at surgical closure. His NRS pain score in

the PACU was 0/10. The patient was continued on

acetaminophen 1 g iv six hourly for the next 24 hr. Two

hours after completion of surgery, he received

hydromorphone 0.5 mg iv for a pain score of 5/10. The

patient’s pain scores subsequently ranged from 2-5/10

during his overnight admission, and he received a total of

three doses of hydromorphone 0.5 mg iv, two doses of

morphine 2 mg iv, and two doses of hydrocodone/

acetaminophen 10/325 mg. He was discharged from the

hospital 20 hr after his arrival in the PACU.

Patient 4

A 67-yr-old female presented for sacral laminoplasty and

microsurgical repair of a Tarlov cyst. She had multiple

reported drug allergies, including morphine, oxycodone,

duloxetine, gabapentin, and topiramate. Bilateral ESP

catheters were placed at T12 and a loading injection of

25 mL 0.375% ropivacaine with 0.25 lg�kg-1

dexmedetomidine and 2 mg dexamethasone was

administered per side. Additional intraoperative

analgesics included hydromorphone 2 mg iv at induction,

acetaminophen 1 g iv, magnesium sulfate 2 g iv pre-

incision, and wound infiltration using 10 mL 0.25%

bupivacaine with 5 lg�mL-1 epinephrine at surgical

closure. Somatosensory evoked potentials were monitored

throughout the case, with no changes noted from the

baseline measurements obtained prior to the ESP block

(Fig. 4).

Her NRS pain score in the PACU was 0/10 and she had

full motor strength on neurologic testing of the lower

extremities. Continuous ESP blockade was commenced in

the PACU using the regimen described above. The patient

received acetaminophen 1 g iv six hourly for the next 72 hr

but did not require any opioids during her admission. Her

NRS pain scores ranged from 1-4/10 during the first 24 hr,

1-3/10 during postoperative hours 24-48, and 1-2/10 during

postoperative hours 48-72. The ESP catheters were

removed just prior to her discharge home on the third

postoperative day.

Patient 5

A 76-yr-old male presented for L1-L3 decompression with

Coflex� interlaminar stabilization. He was taking 800 mg

ibuprofen once or twice per day for low back pain.

Bilateral ESP catheters were placed at T10 and a loading

injection of 25 mL 0.375% ropivacaine with 0.25 lg�kg-1

dexmedetomidine and 2 mg dexamethasone was

administered per side. General anesthesia was maintained

with 55-75 lg�kg-1�min-1 propofol without a volatile

agent. Additional intraoperative analgesics included

fentanyl 250 lg iv at induction, ketamine 20 mg iv,

magnesium sulfate 2 g iv pre-incision, and wound

Fig. 3 A) Bilateral erector spinae plane block catheters inserted at T12 vertebral level prior to surgical incision. B) Subsequent incision for

sacral laminoplasty and Tarlov cyst repair

1060 J. P. Melvin et al.

123

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Erector spinae plane block in spine surgery 1061

123

infiltration using 10 mL 0.5% bupivacaine with 5 lg�mL-1

epinephrine at surgical closure.

The patient’s NRS pain score in the PACU was 0/10.

Continuous ESP blockade was maintained using the

regimen described above and he received acetaminophen

1 g iv six hourly for the next 48 hr. Throughout his hospital

admission, the patient reported NRS pain scores of 0/10

and required no opioids. He had normal motor power in

both lower extremities. The ESP catheters were removed

just prior to his discharge home on the second

postoperative day.

Patient 6

A 55-yr-old male presented for L2-S1 decompression and

excision of a L3-L4 intradural lesion. He was taking

hydrocodone 30-40 mg daily and marijuana twice daily to

manage chronic pain. Bilateral ESP catheters were placed

at T10 and a loading injection of 2 0 mL 0.5% ropivacaine

with 2 mg dexamethasone was administered per side.

Additional intraoperative analgesics included

hydromorphone 2 mg iv at induction, ketamine 0.5

mg�kg-1 iv pre-incision and 0.25 mg�kg-1 every hour,

dexmedetomidine 0.4 lg�kg-1�hr-1, and wound infiltration

using 10 mL 0.25% bupivacaine with 5 lg�mL-1

epinephrine at surgical closure. Somatosensory evoked

potentials were monitored throughout the case, with no

changes noted from the baseline measurements obtained

prior to the ESP block.

His NRS pain score in the PACU was 0/10 and there

was no change from his preoperative neurologic

examination. Continuous ESP blockade was maintained

using the regimen described above. He was started on oral

gabapentin 300 mg every eight hours and acetaminophen 1

g six hourly. He did not receive any postoperative opioids

until the morning of the first postoperative day, when he

was started on oral extended-release oxycodone 10 mg

twice daily to avoid symptoms of opioid withdrawal. No

additional doses of opioid were required during his

admission. He reported NRS pain scores of 0-3/10

during the first 48 hr and 0-2/10 during postoperative

hours 48-72. The ESP catheters were removed just prior to

his discharge home on the third postoperative day.

Discussion

Posterior spine surgery is amongst the most painful

surgical procedures, with median pain scores (using the

0-10 NRS) on the first postoperative day ranging from 5

(spinal decompression) to 7 (spinal fusion).1 Opioids have

traditionally been the mainstay of analgesia therapy, but

they may not always adequately control pain and, at highTa

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1062 J. P. Melvin et al.

123

doses, are associated with significant adverse effects

(sedation, cognitive impairment, constipation) and the

risk of long-term habituation and dependence.2 Regional

anesthesia is an important component of multimodal

analgesic regimens3,4; however, in spine surgery, this has

been primarily confined to neuraxial techniques, namely

epidural analgesia and intrathecal opioid.5,12 These have

side effects and limitations and are not widely used. Local

anesthetic wound infiltration is commonly performed but

its benefit tends to be short-lived.13 Nevertheless, we

employed it in all our patients as a matter of surgical

routine as well as a means of delivering epinephrine to

promote wound hemostasis.

The paraspinal muscles and posterior bony elements of

the spine are innervated by the dorsal rami of the spinal

nerves. These originate shortly after the spinal nerves exit

the vertebral foramina and travel posteriorly through the

intertransverse connective tissues and the paraspinal

muscles to reach the superficial tissues.14 In the ESP

block, local anesthetic spreads within the musculofascial

plane deep to erector spinae muscles and acts on the dorsal

rami of spinal nerves at multiple levels (Fig. 1). Evidence

to date indicates that spread with 20 mL of injectate

extends 3-4 vertebral levels or more from the site of

injection in a caudal direction.8,9,15 Physical spread to the

lumbar paraspinal area from a thoracic site of injection has

also been documented, supporting the existence of a

discrete anatomical pathway.9 We therefore aimed in all

cases to target the T11 or T12 transverse process. This

capacity for extensive cranial-caudal spread is a unique

Fig. 4 Somatosensory evoked potential waveforms recorded from the right and left lower limbs of patient #4, showing no significant changes

following erector spinae plane block

Erector spinae plane block in spine surgery 1063

123

advantage of the ESP block, allowing it to be performed at

a distance from the surgical field, thus minimizing the risk

of microbial contamination and permitting the preoperative

insertion of catheters to prolong postoperative analgesia.

This is in contrast to another recently described regional

analgesic technique for spine surgery, the thoracolumbar

interfascial plane block, which requires injection at a

vertebral level congruent with the surgical site.6,7

The observed lack of impact on intraoperative

electrophysiologic monitoring and the absence of a motor

block16 that might hinder postoperative neurologic testing

and mobilization are additional potential advantages of the

ESP block that should be confirmed in a larger patient

population. The lack of correlation between the degree of

analgesia and motor or sensory block achieved may be

explained by the limited amount of local anesthetic that

actually reaches the lumbar ventral rami or nerve roots.

Low concentrations of local anesthetic applied to nerve

targets have been shown to preferentially inhibit pain

generation and transmission compared with motor and

sensory function.17,18 At the same time, given the need for

relatively large injectate volumes to achieve spread, we

employed the maximum recommended dose of

bupivacaine/ropivacaine in the initial bolus to avoid

excessively low local anesthetic concentrations. While

the ability of dexamethasone and dexmedetomidine to

augment analgesia in ESP blocks is currently

unsubstantiated, we chose to add them to the local

anesthetic mixture based on data from peripheral nerve

blockade19-21 and the principle that opioid sparing is best

achieved by using as many multimodal analgesic strategies

as possible2 rather than relying on a single ‘‘silver bullet’’.

Regarding continuous ESP blockade, we chose a

regimen of intermittent bolus dosing rather than

continuous infusion to again ensure adequate local

anesthetic spread from the catheter tip to the spinal

nerves congruent with the surgical wound. At present,

this choice is based on our understanding of the mechanics

of the ESP block and anecdotal evidence.22 We note,

however, that intermittent boluses appear superior to

continuous infusion in epidural labor analgesia,23 in

contrast to peripheral nerve blockade where the current

evidence is equivocal.24 The former technique is more

relevant to the ESP block given that both rely on local

anesthetic spread within a relatively large anatomical

space. A programmed intermittent bolus function was

unavailable on our pumps and we instead improvised with

a schedule of patient-initiated boluses. In practice, this

worked well because of a high level of motivation amongst

patients and nurses to maintain the degree of analgesia that

was being provided.

In summary, pre-incision ESP blocks performed at the

T10-T12 level contributed to effective perioperative

opioid-sparing analgesia in this preliminary series of six

patients undergoing lumbosacral spine surgery. Catheter

insertion in more major surgeries and patients with

complex pain issues allowed prolongation of this benefit

and avoidance of opioid dose escalation.

Conflicts of interest None declared.

Editorial responsibility This submission was handled by Dr.

Hilary P. Grocott, Editor-in-Chief, Canadian Journal of Anesthesia.

Author contributions Josh P. Melvin conceived the clinical

concept described and contributed to the clinical conduct of the

study, data collection, and writing of the manuscript. Rudolph J.

Schrot and George M. Chu contributed to the clinical conduct of the

study, data collection, and writing of the manuscript. Ki Jinn Chin

contributed to analysis and interpretation of the collected data,

writing, preparation of accompanying figures and material, and

revision of the manuscript.

Funding sources and conflict of interests This work received no

specific funding from any sources.

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